The Oral Medicine workforce and impact on access to care in the United States.

OBJECTIVES: The objective of this study was to characterize the current oral medicine (OM) workforce by examining the distribution of OM diplomates (OMDs) across the Unites States and to determine the need for expanding access to care. STUDY DESIGN: The OMD access was calculated based on the OMDs per 10,000 state population from the 2020 US Census data as well as their distance from state capitals and most populated cities. OMD penetrance in hospitals and cancer centers was assessed at National Cancer Care Network (NCCN) cancer centers, and Best Hospitals as reported in the 2022 US News and World Report (USNWR). RESULTS: OMDs are present in 64% of the states with an uneven geographic distribution. Primary workplaces included dental schools (47%), hospitals (30%), and private practices (19%). Of the OMDs in private practice, 57% limited their practice to OM. OMDs were noted at 28% of NCCN cancer centers, 30% of USNWR Best Hospitals for Cancer, and 20% of USNWR Best Hospitals. CONCLUSIONS: There is low density and uneven distribution of OMDs with approximately one-third of the population without access to an OMD in their state, thus limiting access to care. This suggests both vast opportunities for growth and expansion of OM, as well as challenges in developing and training the necessary workforce. (Oral Surg Oral Med Oral Pathol Oral Radiol YEAR;VOL:page range).

Imiquimod for the treatment of oral leukoplakia: A two-center retrospective study.

OBJECTIVES: We aimed to assess the effectiveness of the use of topical imiquimod for the management of oral leukoplakia (OL). METHODS: This was a retrospective study. Medical chart reviews were conducted to identify patients with biopsy-proven OL treated with topical 5% imiquimod. Data included OL characteristics, histopathological diagnosis, treatment outcome, and adverse events (AEs). Treatment response was assessed by measuring the percentage reduction in the size of OL lesions. RESULTS: 33 patients (51.5% females; median age: 65 years) with 38 lesions were included. OLs were either localized (23.7%) or multifocal lesions (76.3%), with the majority on the gingiva (86.8%). Pretreatment histopathological diagnoses were dysplasia in 84.2% and nonreactive hyperkeratosis in 15.8%. Most regimens consisted of 60-minute applications, 5-days-a-week, for 6 weeks. At the end of treatment, 81.6% of 38 lesions showed a reduction in size with 68.4% exhibiting ≥50% reduction in size, and 42.1% exhibiting complete resolution. Application site reactions were the most common with pain/soreness/sensitivity occurring in 86.8%. Fatigue was the most frequently reported systemic AE (28.9%). CONCLUSION: Two-thirds of OL lesions had ≥50% reduction in size. Most AEs were temporary and resolved upon treatment discontinuation. Prospective studies are needed to further assess Imiquimod's effectiveness in OL management.

Nivolumab for Patients With High-Risk Oral Leukoplakia: A Nonrandomized Controlled Trial.

Importance: Proliferative verrucous leukoplakia (PVL) is an aggressive oral precancerous disease characterized by a high risk of transformation to invasive oral squamous cell carcinoma (OSCC), and no therapies have been shown to affect its natural history. A recent study of the PVL immune landscape revealed a cytotoxic T-cell-rich microenvironment, providing strong rationale to investigate immune checkpoint therapy. Objective: To determine the safety and clinical activity of anti-programmed cell death 1 protein (PD-1) therapy to treat high-risk PVL. Design, Setting, and Participants: This nonrandomized, open-label, phase 2 clinical trial was conducted from January 2019 to December 2021 at a single academic medical center; median (range) follow-up was 21.1 (5.4-43.6) months. Participants were a population-based sample of patients with PVL (multifocal, contiguous, or a single lesion ≥4 cm with any degree of dysplasia). Intervention: Patients underwent pretreatment biopsy (1-3 sites) and then received 4 doses of nivolumab (480 mg intravenously) every 28 days, followed by rebiopsy and intraoral photographs at each visit. Main Outcomes and Measures: The primary end point was the change in composite score (size and degree of dysplasia) from before to after treatment (major response [MR]: >80% decrease in score; partial response: 40%-80% decrease). Secondary analyses included immune-related adverse events, cancer-free survival (CFS), PD-1 ligand 1 (PD-L1) expression, 9p21.3 deletion, and other exploratory immunologic and genomic associations of response. Results: A total of 33 patients were enrolled (median [range] age, 63 [32-80] years; 18 [55%] were female), including 8 (24%) with previously resected early-stage OSCC. Twelve patients (36%) (95% CI, 20.4%-54.8%) had a response by composite score (3 MRs [9%]), 4 had progressive disease (>10% composite score increase, or cancer). Nine patients (27%) developed OSCC during the trial, with a 2-year CFS of 73% (95% CI, 53%-86%). Two patients (6%) discontinued because of toxic effects; 7 (21%) experienced grade 3 to 4 immune-related adverse events. PD-L1 combined positive scores were not associated with response or CFS. Of 20 whole-exome sequenced patients, all 6 patients who had progression to OSCC after nivolumab treatment exhibited 9p21.3 somatic copy-number loss on pretreatment biopsy, while only 4 of the 14 patients (29%) who did not develop OSCC had 9p21.3 loss. Conclusions and Relevance: This immune checkpoint therapy precancer nonrandomized clinical trial met its prespecified response end point, suggesting potential clinical activity for nivolumab in high-risk PVL. Findings identified immunogenomic associations to inform future trials in this precancerous disease with unmet medical need that has been difficult to study. Trial Registration: ClinicalTrials.gov Identifier: NCT03692325.

Immune checkpoint inhibitors in cancer therapy: Review of orofacial adverse events and role of the oral healthcare provider.

Immune checkpoint inhibitors (ICIs) are a revolutionary class of antineoplastic therapy that restore anti-tumor immunity. Consequences of this enhanced immune response include a multitude of immune related adverse events (irAEs) that can affect any body system, including the mouth. Orofacial irAEs reproduce features of numerous immune-mediated conditions, including oral lichen planus, mucous membrane pemphigoid, and Sjögren syndrome, among others. The aim of this review is to summarize known orofacial irAEs and to familiarize oral healthcare providers with how to identify and manage these toxicities as part of the care team for patients treated with ICIs.

Oral manifestations of immune-related adverse events in cancer patients treated with immune checkpoint inhibitors.

Immunotherapy with immune checkpoint inhibitors (ICIs) has transformed cancer treatment over the past decade, improving survival rates in numerous advanced cancers. Immune-related adverse events (irAEs) are common and can affect any organ system, with many of these toxicities being well-characterized with clear grading criteria and management approaches. There has been less emphasis on oral manifestations of irAEs. This review provides an overview of oral manifestations of irAEs, including mucosal and salivary gland toxicities, and proposes a grading system and management guidelines. irAEs are common treatment-related toxicities in patients treated with ICIs. Oral irAEs can range from asymptomatic white reticulations to life-threatening mucocutaneous reactions requiring aggressive management with corticosteroids and/or permanent discontinuation of ICIs. Oral healthcare providers should be prepared to identify and manage oral irAEs in collaboration with oncologists and other specialists.

Higher prevalence of oral human papillomavirus infection in HIV-positive than HIV-negative Thai men and women.

OBJECTIVE: This study was designed to investigate the prevalence of oral human papillomavirus (HPV) infection among HIV-positive and HIV-negative Thai men and women. METHODS: Participants including men who have sex with men (MSM) and heterosexual women were enrolled at the Thai Red Cross Anonymous Clinic in Bangkok. History taking and oral examination were performed by three independent dentists after calibration. HPV infection was evaluated from oral rinse with mouthwash collected at the time of examination. HPV typing was performed by PCR and nucleic acid hybridization to detect thirty-seven HPV DNA genotypes using Linear Array(®) HPV Genotyping Test (Roche Molecular System, Inc.). RESULTS: 244 subjects were enrolled in the study, consisted of 187 HIV-positive (51.9% women and 48.1% MSM) and 57 HIV-negative (21.0% women and 79.0% MSM) Thai subjects. The prevalence of oral HPV infection was 17.2% in HIV-positive subjects whereas only 5.3% of HIV-negative cases had HPV detected in their oral rinses (p=0.0346). Among HIV positive subjects, MSM had higher chance of having HPV infection than females (25% vs. 9.4%, p=0.0074). CONCLUSIONS: HIV-positive Thai MSM and women had higher prevalence of oral HPV infection than those without HIV.